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General Information

First Name: *
Middle Name:
Last Name: *
Gender: *
Male       Female
Date of Birth (MM/DD/YYYY): *
/ /

Physical Street Address

Street Address: *
Apartment unit/floor:
For the purposes of understanding which of the 39 Rhode Island municipalities we should share your information, with please select one of the 39 cities and town below:
City: *
Other city (not in list):
ZIP code: *

Mailing Address as recognized by the US Postal Service
(if different from physical street address)

Street Address:
Apartment unit/floor:
City:
Other city (not in list):
State:
ZIP code:

Contact Information
(* A phone number is required)

Home phone:
Cell phone:
Text only number:
TTY:
Videophone number:
Email:

Emergency Contact

Name:
Phone:
Relationship:
Email:

Living/Housing

I live in Rhode Island (check all that apply to you)
Seasonally from: to:
Year Round
Split my time between multiple Rhode Island addresses
I live in (select one type of housing):
Single Family House
Apartment (Floor: )
Condo / Duplex / Townhouse
Mobile Home
Other
I live (check all that apply to you):
Alone
With family / friends
With caregiver
Group home operated by
Other Group Home
In an independent senior living facility
With other people who are disabled
Other

Language

In what language do you prefer to receive emergency communications or assistance?
English
American Sign Language
Spanish
Portuguese
French
Other

Ethnicity

Do you consider yourself Hispanic or Latino?
Yes
No

Race

Check all that apply:
White
Asian
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
African American/Black
Other

Other Disabilities/Conditions

Diabetes
I use insulin
I weigh between 300 and 549 lbs
I weigh between 550 and 799 lbs
I weigh 800 lbs or greater
Please list other disabilities or relevant conditions:

Life Support Systems

Check all that apply to you:
Oxygen concentrator
I have battery or generator back up for this
Oxygen tanks
I have spare tanks                                                        
Respirator/Ventilator
I have battery or generator back up for this
Tracheostomy
IV line
Urinary catheters
Colostomy/Ileostomy
Feeding tube
Suction
I have battery or generator back up for this
Dialysis at home
I have battery or generator back up for this
Dialysis at a clinic
Pacemaker
Defibrillator
Other electrical needs
None of the above

Sensory

Check all that apply to you:
Visually impaired
Legally blind
Hard of hearing
Deaf
Use of hearing aid(s)
Use of cochlear implant(s)
None of the above

Cognitive, Psychiatric, Neurological, Muscular

Check all that apply to you:
Seizure Disorder
Speech Impaired
Non-verbal
Cognitively / Developmentally Delayed
Autism Spectrum Disorder
Alzheimer's / Dementia
Parkinson's
Cerebral Palsy
Multiple Sclerosis
Depression
Anxiety
Bipolar disorder
Schizophrenia
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder (OCD)
Other
None of the above

Mobility

Check all that apply:
Use a wheelchair/mobility vehicle
Wheelchair/mobility vehicle is power dependent
I have battery or generator back up for this
Confined to a bed
Bed is power dependent
I have battery or generator back up for this
Use a walker/cane
Use crutches
Use prosthesis
Other
None of the above

Transportation

When I leave my home, I most frequently use (check all that apply to you):
Personal vehicle
Taxi/Car service
Public bus
Wheelchair van/bus
Ambulance
RIDE
Bicycle
Other:
If I needed to evacuate, I would be accompanied by (check all that apply to you):
No one
Caregiver
Family/Friend
Other:

Assistance Required

On a normal day, I require assistance with (check all that apply to you):
Feeding myself
Taking medication(s)
Communicating to others
Assistive technology - I use
Transportation
Using the toilet
Dressing/undressing
Bathing/grooming
Transferring from/to
Bed
Wheelchair
Toilet
Shower/tub
Other assistance:
I use a service animal
I require supervision
I receive medical treatment from a nurse/doctor at home
I receive medical treatment from a nurse/doctor at a healthcare facility at least once a week
Other:
None of the above

How Did You Hear About Us?

How did you hear about the Rhode Island Special Needs Emergency Registry?

An outreach event Family/friend Mailing Advertisement (social media, television, etc.) Healthcare worker Other:

Complete Registration

NOTE: By submitting this form to RIEMA/HEALTH, I agree to permit my information to be shared with local and state emergency responders. I understand that this is a voluntary program and while RIEMA/HEALTH will share this information in order to better assist me during an emergency, they cannot guarantee assistance in all cases.

I agree           I do not agree


If you are completing this form on someone's behalf, please indicate your name and relationship to that individual:

Name:
Relationship: